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Systematic Review (Pages: 1255-1271)
Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan
University of Science and Technology, Irbid, Jordan.
2
Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science
and Technology, Irbid, Jordan.
3
Department of Pediatrics and Neonatology, Faculty of Medicine, Jordan University of Science and Technology,
Irbid, Jordan.
4
School of Natural Resources Engineering and Management, German Jordanian University, Amman, Jordan.
5
Department of Applied Biological Sciences, Faculty of Science and Arts, Jordan University of Science and
Technology, Irbid, Jordan.
6
Centre for Environmental Health Activities, Regional Office for the Eastern Mediterranean, WHO, Genve,
Schweizer.
Abstract
The East Mediterranean region (EMR) suffers from high levels of air pollution which has a
negative impact on pregnancy outcomes. This work systematically reviews the epidemiological
evidence on maternal exposure to air pollution and adverse pregnancy outcomes in the region.
Relevant papers and reports published between 2000 and 2014 were searched. Combinations of search
terms including countries, exposures, and pregnancy outcomes were used to search for the relevant
literature. Twelve articles from 6 countries met the inclusion criteria. There was a pattern of an
association between outdoor air pollution and preterm birth and spontaneous abortion; indoor wood
fuel smoke and birth weight; and second-hand smoke and birth weight, preterm birth, and
spontaneous abortion.
The quality of evidence on the impact of air pollution on pregnancy outcomes in the EMR is
inadequate to form a base for future adaptation strategies and action plans. Therefore, more quality
research is needed to portrait the actual situation in the region
Key Words: Air pollution; East Mediterranean region; Pregnancy outcomes.
*Please cite this article as: Khader Y, Abdelrahman M, Abdo N, Awad S, Al-Sharif M, Elbetieha A, et al.
Exposure to Air Pollution and Pregnancy Outcomes in the East Mediterranean Region: a Systematic Review. Int
J Pediatr 2016; 4(1): 1255-71.
*Corresponding Author:
Prof. Yousef Khader, Department of Community Medicine, Public Health and Family Medicine, Faculty of
Medicine, Jordan University of Science and Technology, Ibrid, Jordan. Fax: +962 (0) 2 720 1064.
Email: yskhader@just.edu.jo
Received date Dec 3, 2015 ; Accepted date: Dec 28, 2015
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1-INTRODUCTION
It is well established now that air
pollution has significant association with
human mortality and morbidity. Exposure
to particulate matter (PM) of sizes less
than 10 m (PM10) and 2.5 m (PM2.5) and
gaseous pollutants including nitrogen
dioxide (NO2), sulfur dioxide (SO2),
monoxide (CO), and ozone (O3), have been
associated with increased risk of morbidity
and mortality (1). Despite the recognition
of the serious health hazards of air
pollution, most of the countries in the East
Mediterranean Region (EMR) still do not
have adequate regulations and/or systems
for monitoring air pollution. Data from the
WHO 2014 database on air pollution
shows that out of the 1 524 cities that are
reporting PM10 data from 91 countries
globally, only 26 cities from 10 countries
are in the EMR, all of which exceed the
WHO Air Quality Guidelines (AQG) for
annual concentration of 20 g/m3 (2).
Computer models and satellite-derived
maps also provide strong evidence that
almost all countries of the EMR exceed the
WHO guidelines for annual mean of PM2.5
(10 g/m3). In fact, the highest PM
readings come from the EMR. In addition,
indoor air pollution from coal and biomass
fuel burning for cooking and heating
present a serious issue in some low to
middle income countries in the EMR such
as Somalia, Afghanistan, Sudan, and
Pakistan, where about 100%, 80%, 70%,
and 58% of the population use solid fuel
for energy compared to 40% globally (3).
Solid fuel combustion smoke along with
the household passive exposure to
cigarettes and hookah smoke comprise a
major biohazard, especially for women in
some EMR countries who often spend
hours cooking in insufficiently ventilated
kitchens and exposed to Secondhand
Smoke (SHS) from the husband and/or
children (2). A dramatic example is
Pakistani mothers who, in addition to the
very high ambient air pollution, are very
Int J Pediatr, Vol.4, N.1, Serial No.25, Jan 2016
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adjustment
for
confounders.
The
association between SHS and LBW was
investigated in 6 studies (22, 23, 27, 29,
30, 31). Multivariate logistic regression
was used to calculate the odds ratio after
adjustment for potential confounders. In
Jordan, exposed women at home and at
work were found to be approximately 1.5
times (OR: 1.56; 95% CI: 1.31, 1.89) more
likely to deliver a LBW baby compared to
unexposed women (27).
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Khader et al.
Pollution
and
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1.
Limited number of studies: A
limited number of studies for a limited
number of outcomes in a limited number
of regions have assessed the association
between various exposures and pregnancy
outcomes. Therefore, research on air
pollution and pregnancy outcomes is
sporadic and insufficient to render a robust
evidence for the situation in the EMR.
More research is needed to sufficiently
represent
the
different
geographic
locations and topography of the countries
(38), to further investigate the currently
studied outcomes, to identify susceptible
subpopulation, and to study other
pregnancy outcomes such as SGA, IUGR,
congenital abnormalities, and late fetal
mortality.
2.
Lack of precise estimation of
exposure: Except for one study (24),
outdoor air pollution measurements were
based on stationary air pollution
monitoring, instead of personal exposure.
This method does not account for potential
sources other than ambient air such as the
personal macro- (e.g., living next to a busy
road) and microenvironment (e.g., SHS
exposure at home (26, 43). Also, relying
on residential address to estimate exposure
based on the distance from a monitoring
station critically ignores the subject
mobility (38). In addition, exposure to
SHS and indoor wood fuel smoke was
based on womens retrospective self
reporting, instead of the use of biomarker
to verify exposure, which may result in
imprecision and recall bias (22, 23, 42).
The association between self-reported
exposure status to SHS and urinary
cotinine in nonsmokers has been reported
to be poor (44, 45). It is recommended that
a combination of different methods of
assessing SHS exposure is often the best
approach (46).
3.
Inconsistent exposure metrics:
Different metrics have been used to
quantify outdoor air pollution exposure in
the EMR (e.g., continuous daily average
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Khader et al.
Environmental
health
2014;122(3):317-23.
perspectives
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Original Article (Pages: 429-434)
Country
Irbid,
Jordan
Study
Year
---
Exposure
SHS
Pregnancy
Outcome
BW
Study Design
Population
Cross-sectional study on
300 births in one hospital
Exposure
Assessment
Personal
interview-based
questionnaire
Outcome
Assessment
Hospital
records
Confounders Adjusted
Neonates gender, gestational age, number of mothers
previous pregnancies, weight gain during pregnancy,
initiation of prenatal care, maternal age, maternal height,
maternal weight before pregnancy, mothers years of
education, mothers occupation during pregnancy, and total
family income
Main results:
Number of SHS exposure hours per week during the second semester from home and from work had a negative association with the neonatal BW (: -0.38* and -0.25* respectively).
Exposure to SHS from home and from outside during the third trimester, and from work during the second trimester increased the odds of having an LBW infant [OR (95% CI) for every hour/week
increase in exposure time: 1.08* (1.03, 1.12), 1.15* (1.06, 1.26), and 1.33* (1.05, 1.68) respectively].
Abusalah A
et al. (2012)
Gaza
strip,
Palestine
2007
SHS,
wood fuel
smoke
BW
Personal
interview-based
questionnaire
Clinician
delivery
at
Main results:
Women chronically exposed to wood fuel smoke had lighter infants than unexposed women [adjusted mean difference (95%CI): -186 g* (-354, -19 g)]. They also were at higher risk of having an LBW
infant [OR (95% CI): 2.3* (1.2, 4.7)].
There was a dose-response relationship between MBW and SHS. Chronic exposure to the smoke of 120 cigarettes/day had smaller effect on MBW than 21 cigarettes/day [adjusted mean difference
(95%CI): -237 g* (-415, -58 g) and -391 g* (-548, -28 g) respectively). In addition, chronic exposure to the smoke of 120 cigarettes/day increased the odds of having an LBW infant by 2.5* times (95%
CI: 1.4, 4.3), whereas the exposure 21 cigarettes/day raised the odds further to 4.6* times (95% CI: 1.9, 10.7).
Al-Saleh et
al. (2013)
Al-Kharj,
Saudi
Arabia
2005
2006
PAH
BW; CHL; HC
A cross-sectional study
on 1,578 births in one
hospital
Non-smoker; No
history of occupational
exposure
Blood PAH
concentrations
Hospital
records
Hospital
records
None
Main results:
No significant association was found between the placental PAH (log10) level and any of the studied pregnancy outcomes.
Amasha &
Amman
Jaradeh
& Zarqa,
(2012)
Jordan
Main results:
2009
SHS
PTB; CM
A cross-sectional study
on 223 births in 4
hospitals
Personal
interview-based
questionnaire
PTB had significantly higher prevalence among women chronically exposed to SHS (22.3%) than unexposed women (10.7%)
There was no significant difference in the prevalence of CM among women chronically exposed to SHS compared to the unexposed women.
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Table 1: Continued...
Authors
(Year)
Araban et
al. (2012)
Country
Tehran,
Iran
Study
Year
2007
Exposure
CO, O3, NO2,
SO2, PM 10
Pregnancy
Outcome
BW
Study Design
Cohort study on 225
births in 6 hospitals
Population
Aged 1835 years;
Singleton pregnancy;
Living within 5 km of a
unique air pollution
monitoring station; Had
at least 2 prenatal care
visits
during their
pregnancy
Exposure
Assessment
Average
concentration of
pollutants
obtained from the
nearest monitoring
station (within a 5
km radius)
Outcome
Assessment
Hospital
records
Confounders Adjusted
Maternal age, maternal education, maternal job,
socioeconomic factor, stress status, number of prenatal care
visits, weight gain during pregnancy, gestational age, sex of
the baby and planned pregnancy
Main results:
Women exposed to CO during the entire pregnancy and during the second trimester were at higher risk of having an LBW infant [OR for every For IQR increase in concentration (95% CI): 2.08* (1.70,
4.60) and 3.96* (1.83, 12.5) respectively].
There was no evidence on the association between the exposure to the other pollutants during the entire pregnancy or the different trimesters and LBW.
Janghorbani
& Piraei
(2013)
Isfahan,
Iran
2010
2012
CO, O3,
NO2, SO2,
PM10
BW; PTB
PSI calculated
from average
concentration of
pollutants
obtained from the
nearest monitoring
station
Clinician at
delivery
Main results:
There was no evidence on the association between the exposure to outdoor air pollution during the entire pregnancy or the different trimesters and LBW
Exposure to outdoor air pollution during the entire pregnancy was associated with PTB [OR for IQR increase in PSI (95% CI): 1.26* (1.201.33)].
Khader et
al. (2011)
Northern
Jordan
2007
SHS
BW; PTB
A cross-sectional study
on 8,490 births in 4
hospitals
Personal
interview-based
questionnaire
Clinician at
delivery
Main results:
Women exposed to SHS at home and at work during the entire pregnancy gave birth to lighter infants (mean difference: 140 g*) and were at higher risk of having an LBW infant than unexposed women
[OR (95% CI): 1.56* (1.31, 1.89)].
They were also at higher risk of having a PTB [OR (95% CI): 1.61* (1.301.99)].
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Table 1: Continued...
Authors
(Year)
Moridi et
al. (2014)
Country
Tehran,
Iran
Study
Year
2010
2011
Exposure
CO, O3,
NO2, SO2,
PM10
Pregnancy
Outcome
SA
Study Design
Population
Retrospective case
control study on 148
matched pairs of women
who experienced SA
before 14 weeks of
gestation (case) and
pregnant women after 14
weeks of gestation
(control) in 10 hospitals
Exposure
Assessment
Average
concentration of
pollutants
obtained from the
nearest monitoring
station
Outcome
Assessment
Hospital
records
Confounders Adjusted
Maternal age, husband age, gravidity, duration from last
delivery in multiparous women, history of previous
abortion, pre-pregnancy BMI, occupation, educational
status, SHS exposure, socioeconomic status, consanguinity
with the spouse and duration of residence in Tehran.
Main results:
There was a significant association between the exposure to CO during the entire pregnancy and SA [OR for every 1 ppm increase in CO (95% CI): 1.95 (1.50, 2.55)]
There was a weak, but significant, association between the exposure to NO 2, O3, and PM10 during the entire pregnancy and SA [OR for every 1 ppb increase in NO 2 and O3 concentration (95% CI): 1.04*
(1.02, 1.05) and 1.09* (1.06, 1.13) respectively; OR for every 1 g/m3 increase in PM10 concentration (95% CI): 1.01* (1.00, 1.02)]
There was no evidence on the association between the exposure to SO 2 during the entire pregnancy and SA.
Siddiqui et
al. (2008)
Rehri
Goth,
Pakistan
2004
2005
Wood fuel
smoke
BW
Singleton pregnancy
Personal
interview-based
questionnaire
Hospital
records
Main results:
Wood fuel women users had lighter infants than gas fuel women users (adjusted mean difference: -82 g). They also were at higher risk of having a LBW baby [OR (95% CI): 1.86* (1.11, 3.14)]
Wadi and
AlSharbatti
(2011)
Baghdad,
Iraq
2004
SHS
BW
Retrospective cohort
study on 300 births in one
hospital; 150 housewife
mothers not exposed to
passive smoking at home
and 150 exposed
Healthy; Singleton
pregnancy; Nonsmoker
Personal
interview-based
questionnaire
Hospital
records
Main results:
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Table 1: Continued...
Authors
(Year)
Wahabi et
al. (2013)
Country
Riyadh,
Saudi
Arabia
Study
Year
2011
2012
Exposure
SHS
Pregnancy
Outcome
BW; CHL; HC
Study Design
Retrospective cohort
study on 3,231 women in
one hospital
Population
Singleton pregnancy;
Did not smoke during
pregnancy
Exposure
Assessment
Personal
interview-based
questionnaire
Outcome
Assessment
Hospital
records
Confounders Adjusted
Maternal age, parity, BMI, GDM and gestational age
Main results:
Women chronically exposed to SHS had lighter infants than unexposed women (mean difference: 50 g*)
Exposure to SHS was associated with increased rate of LBW infants, irrespective of maternal BMI.
The odds of delivering an LBW infant was 2.71* times (95% CI: 1.82, 4.05) higher in underweight women (BMI < 18 kg/m2) chronically exposed to SHS compared to non-obese (1829.9 kg/m2) exposed women
The odds of delivering an LBW infant was 2.15* times (95% CI: 1.01, 4.73) higher in obese women (BMI 30 kg/m2) chronically exposed to SHS compared to non-obese exposed women
Women chronically exposed to SHS gave birth to infants with significantly shorter crown-heel length (mean difference: 2.0 mm*) and head circumference (mean difference: 1.3 mm*) than unexposed women.
Wahabi et
al. (2013)
Riyadh,
Saudi
Arabia
2011
2012
SHS
BW; CHL; HC
Retrospective cohort
study on 3,426 women in
one hospital
Singleton pregnancy;
Did not smoke during
pregnancy
Personal
interview-based
questionnaire
Hospital
records
Main results:
Women chronically exposed to SHS had lighter infants and infants with shorter crown-heel lengths [adjusted mean difference (95% CI): 2.61 mm (0.58, 4.64)] than unexposed women [adjusted mean difference (95% CI): 35 g* (2,
68)]. Head circumference was also shorter in infants of exposed women (mean difference: 0.9 mm); however, the difference was not statistically significant.
BMI: body-mass index; BW: birth weight; CHL: crown-heel length; CI: confidence interval; CM: congenital malformation; HC: head circumference; LBW: low mean birth weight; MBW: mean birth
weight; OR: odds ratio; PM10: particulate matter of sizes < 10 m; PTB: preterm birth; SA: spontaneous abortion; SHS: second-hand smoke.
* P < 0.05
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Original Article (Pages: 429-434)
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